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JC: The Quick-Wee Method for Faster

Clean Catch Urine Collection
Natalie May on April 10, 2017

The wilful nature of children is responsible for a lot of the facial expressions we
see in the paediatric emergency department but few parents are as frustrated
as those waiting… and waiting… and waiting for the short-lived, poorly-timed,
inevitable fountain or dribble of urine they are expected to catch Translate »
in a sterile pot
or bowl for the exclusion of urinary tract infection as a cause of their child’s
symptoms. Many imagine a world where their child simply passes urine on
demand. And now, in 2017, seven authors from Australia1 seem to be offering
us just that. Well, almost…

First of all please note that this paper is Open Access – so there is no excuse
for not spending a bit of time with the original article before reading on below!

What is this paper about?

The hypothesis of this study is that the Quick-Wee method (detailed below) can
speed up the collection of urine samples from infants in the Emergency
Department compared with control – usual care, meaning washing the genitals
to reduce contamination then standing around with a pot. Of course, this isn’t
the only option; if you don’t care about sterility, urine bags are an option (but the
rates of contamination are probably unacceptably high for infants, in whom
NICE recommends that further investigations might be indicated in the presence
of a conTrmed UTI); catheter-specimens and suprapubic aspirates have lower
contamination rates but are considerably invasive. As a result for most children
we end up waiting around for that elusive specimen.

The authors are following on from their published trial protocol2 (also Open
Access) with the results of their study.

What did they do?

The Quick-Wee method they describe involves using cold water (theirs was
refrigerated to 2.8ºC), soaked onto gauze held in plastic forceps and wiped on a
circular motion over the suprapubic area for up to Tve minutes following initial
cleaning for 10 seconds with room temperature sterile water (this cleaning was
undertaken in both the control and intervention groups).

Patients attending the ED aged 1-12months for whom a urine sample was
required were identiTed by ED clinicians and randomly, sequentially allocated to
a treatment arm using opaque envelopes (allocation concealment) determined
in order by random permuted blocks. The authors note that blinding was not
possible due to the nature of the Quick-Wee intervention but it’s possible that
they have missed other blinding opportunities (such as blinding of the data
analysts to the groups during preparation of the manuscript3).

Babies under a month old were excluded because of the relative importance of
neonatal sepsis; in the institution in question, catheter or SPA specimen is
preferred in order to be as accurate as possible. The other exclusions seemed
sensible too; anatomical or neurological anomalies precluding normal
suprapubic sensation would make the intervention meaningless.

In total 344 patients were analysed: 174 were randomised to the Quick-Wee
technique and 170 to standard watch-and-wait. The authors had carried out a
sample size calculation and very sensibly added 10% to allow for later
exclusions or dropouts so they were actively over-recruiting to the study, and
this seemed to pay off since their required sample size was 322 (161 in each
group), which they achieved despite 10 exclusions/withdrawals after
randomisation.

The primary outcome was passage of urine within Tve minutes of the clock
being started – or not. This binary outcome lends itself well to ????2 testing,
where proportions of the outcome are compared between the two groups.
Several secondary outcomes were considered, including whether the urine was
actually caught, the contamination rates (assessed subsequently) and both
parents and clinician satisfaction with the method of obtaining the sample.
These are all reasonable outcomes in which we are interested as Emergency
Physicians, but it’s important to remember that results in these areas are
observational at best as they are not the outcomes around which the study was
designed or powered.

What’s particularly positive about this study is that everything to do with

delivering the study intervention was conducted within the department; patient
selection, the intervention itself, the data collection including the results. This is
unusual in published studies and certainly adds to the applicability of Tndings to
an ED population.

What did they find?

There was a statistically signiTcant difference in the primary outcome; in the
control group a urine sample was obtained in 20/170 subjects (12% – 95%
conTdence interval 7%-18%) compared with 54/174 subjects in the intervention
(Quick-Wee) group (31% – 95% conTdence interval 24%-39%). This gave a
difference in proportions of 19% (95% CI 11%-28%) which doesn’t quite add up
but is, I assume, related to mathematical rounding. In any case the conTdence
interval is nowhere near zero so we can be reasonably sure that the true
population value would be in favour of Quick-Wee.

When they looked at whether the voided sample was actually caught, that was
higher in the Quick-Wee group too (30% vs 9%), presumably refecting how
continued attention to the genital area makes us more likely to catch the urine
when it comes.
In addition, the authors found slightly lower (but not statistically signiTcant)
contamination rates – 27% with Quick-Wee, 46% with control – but these
subgroups were small in size and consequently the results have wide
conTdence intervals attached. A larger, multi-centre study might be able to
evidence lower contamination rates with the Quick-Wee technique, something
which would certainly sway us towards using it in the ED – but given the time
delay in determining the presence of organisms and identiTcation of pure
growth versus contaminant, we would likely need an enormous sample size for
that particular study.

Lastly, the assessment of satisfaction with the technique fell in favour of Quick-
Wee both for parents and clinicians. The use of a Likert-scale here is a little
confusing as 1=very satisTed and 5=very unsatisTed so a higher score actually
means lower satisfaction, in addition to being a crude assessment of the
acceptability of this technique, but at least both groups seemed to prefer it over
standard care. I do wonder how much of this was the effect of the novelty of the
technique, though.

What does this mean?

You might remember a similar technique, published by Herreros et al in Archives
of Disease in Childhood back in 20134 and covered in this ALIEM post. Their
technique involved prehydration, washing of the genitals and then alternately
rubbing the lower back and tapping the suprapubic area of neonates held under
the armpits by a second party, legs dangling. The subtle difference in this
current publication, the authors tell us, is that it was undertaken in the ED
instead of NICU and it does not involve suspending the child aloft in anticipation
of the sample being obtained. Playing Devil’s advocate, I would point out that in
the ADC study the success rate was substantially higher (86%, albeit with a far
smaller sample and without a sample size calculation) and that the median time
to collection was given – just 57seconds. This data is not reported in the Quick-
Wee study and it would certainly be nice to see.
In any case, this method seems to be worth a try as a Trst line attempt at
obtaining a urine sample. The biggest challenge I can foresee is not the
provision of cold fuid (every Emergency Department should have a drug fridge
for insulin etc.) nor the training of ED staff but the fact that the staff members
performing the intervention have to do so for Tve interrupted minutes. Aside
from the fact that I doubt the attention span of the average Emergency
Physician is that long, there’s good evidence that we are interrupted A LOT –
30.9 times in 180 minutes in one study5 – and I’m sure our ED nurses are
exactly the same. Performing the Quick-Wee technique continuously for Tve
minutes might be almost impossible in a busy ED. But from the results of this
study, that probably shouldn’t preclude us from giving it a wee go :).

Further Reading
The SGEM – coming soon!

PEMLit – What are Wee Waiting for?

Nat

@_NMay

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1. Kaufman J, Fitzpatrick P, Tosif S, et al. Faster clean catch urine collection

(Quick-Wee method) from infants: randomised controlled trial. BMJ.
2017;357:j1341. [PubMed]
2. Kaufman J, Fitzpatrick P, Tosif S, et al. The QuickWee trial: protocol for a
randomised controlled trial of gentle suprapubic cutaneous stimulation to
hasten non-invasive urine collection from infants. BMJ Open.
2016;6(8):e011357. [PubMed]
3. Polit D. Blinding during the analysis of research data. Int J Nurs Stud.
2011;48(5):636-641. [PubMed]
4. Herreros F, González M, Tagarro G, et al. A new technique for fast and safe
collection of urine in newborns. Arch Dis Child. 2013;98(1):27-29. [PubMed]
5. Chisholm C, Collison E, Nelson D, Cordell W. Emergency department
workplace interruptions: are emergency physicians “interrupt-driven” and
“multitasking”? Acad Emerg Med. 2000;7(11):1239-1243. [PubMed]
CATEGORY:
#FOAMed, Emergency Medicine, Exam material, Featured, Journal Club, Paeds

TAG:
#FOAMed, CC21, EBM, evidence based medicine, FOAMped, journal club, PAP9, Quick-
Wee, urine collection

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Posted by Natalie May

Dr. Natalie May, MBChB, MPHe, MSc, PGCert Medical Education,
FRCEM, FACEM is section lead for paediatrics and medical
education. She is an Editorial Board Member of the St Emlyn’s blog
 and podcast. She is a specialist in Emergency Medicine (Australia)
and a Specialist in Emergency Medicine with Paediatric
Emergency Medicine (UK). She works as Staff Specialist in
Prehospital and Retrieval Medicine with the Ambulance Service of
New South Wales (aka Sydney HEMS). She also works as aStaff
Specialist, Emergency Medicine, St George Hospital (South
Eastern Sydney Local Health District). Her research interests
include medical education, particularly feedback; gender inequity
in healthcare; paediatric emergency medicine. You can Tnd her on
twitter as @_NMay

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